SURGICAL PATIENT GUIDE - OhioHealth

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OhioHealth Weight Management SURGICAL PATIENT GUIDE Our comprehensive, individualized approach sets us apart. Learn more at OhioHealth.com/WeightManagement.

Table of contents Why OhioHealth Weight Management is right for you. 4 Meet our surgeons.5 What is obesity?. 6 Body mass index calculator.7 Medical options for severe obesity. 8 Surgical options for severe obesity. 9 Laparoscopic gastric bypass. 10 Why select a gastric bypass procedure?. 11 The laparoscopic gastric sleeve procedure.13 Risks of laparoscopic gastric bypass or laparoscopic gastric sleeve procedures.14 Laparoscopic surgery – the preferred method. 15 Pros and cons of two bariatric operations.16 Eligibility requirements for bariatric surgery . 17 Free seminars.18 Presurgical evaluation. 19 Surgery preparation.20 Postsurgical treatment plan.21 Getting started. 22 Evaluation request. 25 Seminar evaluation. 27 2 OhioHealth Weight Management Surgical Patient Guide OhioHealth.com/WeightManagement 3

Why OhioHealth Weight Management is right for you Meet our surgeons OhioHealth Surgical Weight Management can help you transform your health and life through safe, minimally invasive surgical approaches to sustainable weight loss. Bariatric Surgery and General Surgery Our program is unique because our support extends beyond your procedure. Your care team will compassionately guide you at every step of your journey, leading up to your surgery and afterward as we help you navigate the physical, emotional and social effects of weight loss. OhioHealth Physician Group Our fellowship-trained bariatric surgery physicians specialize in minimally invasive weight loss surgeries, including laparoscopic Roux-en-Y gastric bypass surgery and sleeve gastrectomy surgery. We take a holistic approach to weight loss, providing both the physical and emotional support you need to succeed. Surgical care is provided at OhioHealth Riverside Methodist Hospital. Our strengths: A holistic approach to care. A commitment to excellence and personalized care. Experienced surgeons. Short hospital stays – patients typically return home within three days. Superior quality – surgeries are performed at OhioHealth Riverside Methodist Hospital, one of the nation’s best hospitals. Support, guidance and therapy to increase your activity level. Our surgical program Weight loss is more than an operation, and so is our program. You will be provided with: Free seminars. A thorough medical review. A presurgical evaluation. Presurgical preparation. Minimally invasive surgery. Excellent care from the Riverside Methodist Magnet nursing team. Extensive, specialized nutritional counseling before and after surgery. Postsurgical follow-up visits. Emotional and social support. Thomas E. Sonnanstine, MD, FACS, FASMBS Nirav R. Rana, MD, FACS, FASMBS T. Calloway Robertson, MD Education and Training Education and Training Education and Training Board Certification: General Surgery Board Certification: General Surgery Board Certification: General Surgery Medical School: Northeast Ohio Medical University Medical School: Northeast Ohio Medical University Medical School: Loyola University Chicago, Stritch School of Medicine Residency: OhioHealth Riverside Methodist Hospital Residency: St. Vincent’s Catholic Medical School, New York Residency: OhioHealth Riverside Methodist Hospital Fellowship: Minimally invasive and bariatric surgery, Tufts Medical Center, Boston Fellowship: Minimally invasive and bariatric surgery, Cedars-Sinai Medical Center, Los Angeles Fellowship: Minimally invasive and bariatric surgery, Carolinas Medical Center, Charlotte, North Carolina Medical Director Exercise guidance to increase your activity level and manage your weight long-term. 4 OhioHealth Weight Management Surgical Patient Guide OhioHealth.com/WeightManagement 5

What is obesity? Body massBindex calculator ody Mass Index Calculator Medically significant obesity is defined as obesity that either is causing disease or is highly likely to cause disease. Morbid obesity is often defined as being greater than 100 pounds overweight. More specifically, it is having a body mass index (BMI) of greater than or equal to 40. BMI is calculated as weight in kilograms divided by height in meters squared. Patients with a BMI between 35 and 40 are considered to have severe obesity and meet criteria for these operations if they are developing obesity-related medical problems, such as diabetes, high blood pressure and obstructive sleep apnea. World health organization weight definitions Ideal weight: 20–24.9 BMI Severe obesity: 35–39.9 BMI Overweight: 25–29.9 BMI Morbid obesity: 40–49.9 BMI Moderate obesity: 30–34.9 BMI Super morbid obesity BMI greater than 50 The weight of Americans is increasing at an alarming rate. One out of four Americans is considered obese. Obesity is the second leading cause of preventable death, second only to tobacco use. Obesity is related to approximately 300,000 deaths per year in the United States. People with morbid obesity die eight to fifteen years earlier than non-obese people. Common health conditions related to obesity Diabetes Respiratory disease Depression Colon, prostate, breast, uterine and ovarian cancer Hypertension Joint and back pain Sleep apnea Hyperlipidemia (high cholesterol) Cardiac disease Gastroesophageal Reflux Disease (GERD) Arthritis Stress incontinence Gallbladder disease Infertility Menstrual irregularities HT/INCHES 60 140 27 150 29 160 31 170 33 180 35 190 37 200 39 210 41 220 43 230 45 240 47 250 48 260 50 270 52 280 54 290 56 300 58 310 60 320 62 330 64 340 66 350 68 360 70 370 72 380 74 390 76 400 78 410 80 420 81 430 83 440 85 WT/LBS 450 460 470 480 490 500 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 26 28 30 32 34 36 38 39 41 43 45 47 49 51 53 54 56 58 60 62 64 66 68 69 71 73 75 77 79 81 83 84 25 27 29 31 33 34 36 38 40 42 44 45 47 49 51 53 54 56 58 60 62 64 65 67 69 71 73 74 76 78 80 82 83 85 Does not meet criteria 6 OhioHealth Weight Management Surgical Patient Guide 25 26 28 30 32 33 35 37 39 40 42 44 46 47 49 51 53 54 56 58 60 62 63 65 67 69 70 72 74 76 77 79 81 83 84 24 26 27 29 31 32 34 36 38 39 41 43 44 46 48 49 51 53 55 56 58 60 61 63 65 66 68 70 72 73 75 77 78 80 82 84 85 23 25 26 28 30 31 33 35 36 38 40 41 43 45 46 48 49 51 53 54 56 58 59 61 63 64 66 68 69 71 73 74 76 77 79 81 82 22 24 26 27 29 30 32 34 35 37 38 40 42 43 45 46 48 50 51 53 54 56 58 59 61 62 64 66 67 69 70 72 74 75 77 78 80 22 23 25 26 28 29 31 33 34 36 37 39 40 42 43 45 47 48 50 51 53 54 56 57 59 61 62 64 65 67 68 70 71 73 74 76 78 21 23 24 26 27 29 30 32 33 35 36 38 39 41 42 44 45 47 48 50 51 53 54 56 57 59 60 62 63 65 66 68 69 71 72 74 76 21 22 23 25 26 28 29 31 32 34 35 37 38 40 41 43 44 45 47 48 50 51 53 54 56 57 59 60 62 63 64 66 67 69 70 72 73 20 21 23 24 26 27 28 30 31 33 34 36 37 38 40 41 43 44 46 47 48 50 51 53 54 56 57 58 60 61 63 64 66 67 68 70 71 21 22 24 25 26 28 29 30 32 33 35 36 37 39 40 42 43 44 46 47 48 50 51 53 54 55 57 58 60 61 62 64 65 66 68 69 20 22 23 24 26 27 28 30 31 32 34 35 36 38 39 40 42 43 44 46 47 49 50 51 53 54 55 57 58 59 61 62 63 65 66 67 20 21 22 24 25 26 27 29 30 31 33 34 35 37 38 39 41 42 43 44 46 47 48 50 51 52 54 55 56 58 59 60 61 63 64 65 20 22 23 24 25 27 28 29 31 32 33 34 36 37 38 40 41 42 43 45 46 47 48 50 51 52 54 55 56 57 59 60 61 62 64 20 21 22 24 25 26 27 29 30 31 32 33 35 36 37 38 40 41 42 43 45 46 47 48 50 51 52 53 55 56 57 58 60 61 62 21 22 23 24 25 27 28 29 30 31 33 34 35 36 37 39 40 41 42 43 45 46 47 48 49 51 52 53 54 55 57 58 59 60 20 21 22 23 25 26 27 28 29 31 32 33 34 35 36 38 39 40 41 42 43 45 46 47 48 49 51 52 53 54 55 56 58 59 Meets criteria if high blood pressure, diabetes or obstructive sleep apnea are present 21 22 23 24 25 26 27 29 30 31 32 33 34 35 37 38 39 40 41 42 44 45 46 47 48 49 50 52 53 54 55 56 57 20 21 22 23 25 26 27 28 29 30 31 32 33 35 36 37 38 39 40 41 42 44 45 46 47 48 49 50 51 52 54 55 56 20 21 22 23 24 25 26 27 28 29 31 32 33 34 35 36 37 38 39 40 41 42 44 45 46 47 48 49 50 51 52 53 54 Meets criteria OhioHealth.com/WeightManagement 7

Nonsurgical options for severe obesity There are many nonsurgical approaches to weight loss. They include programs that are not medically supervised, like Weight Watchers , Jenny Craig or self-help resources such as those found through the Centers for Disease Control or WebMD. Some primary care physicians may also provide medical treatments or refer patients to a medical weight loss program. The American Society of Metabolic and Bariatric Surgeons concluded that bariatric surgery provided as part of a multidisciplinary team is “the most effective therapy available for morbid obesity and can result in improvement or complete resolution of obesity comorbidities.” 1 Multiple randomizedcontrolled trials have shown greater weight loss among patients who have undergone bariatric surgery compared to those receiving conventional medical therapy.2,3,4 If you are not sure surgery is right for you OhioHealth Weight Management offers an excellent, medically supervised, nonsurgical weightloss program. Our multidisciplinary approach addresses the complex nature of obesity by including dietary changes as well as exercise and behavior modification. Our medically supervised program is designed for individuals who desire a nonsurgical option for significant weight loss or are not eligible for bariatric surgery. It includes one-on-one time with our weight-loss experts – physicians, dietitians, exercise physiologists and behavioral counselors – along with weekly group classes. We ensure a safe weight-loss experience and provide the support and information needed to achieve lifelong success. 1 American Society Of Metabolic And Bariatric Surgeons (2004). Consensus Statement. Available At: Http://Asmbs.org/2012/06/Consensus-Statement/. Accessed Jan 22, 2013. 2 Mingrone G, Panunzi S, De Gaetano A, Et Al. Bariatric Surgery Versus Conventional Medical Therapy For Type 2 Diabetes. New Engl J Med 2012 Apr 26;366(17):1577-85. 3 Colquitt Jl, Picot J, Loveman E, Clegg Aj. Surgery For Obesity. Cochrane Database Syst Rev 2009 Apr 15; (2):Cd003641. 4 Maggard Ma, Shugarman Lr, Suttorp M. Meta-Analysis: Surgical Treatment Of Obesity. Ann Intern Med 2005 Apr 5;142(7):547-59. Surgical options for severe obesity Thanks to advances in minimally invasive laparoscopic techniques, more and more people are selecting bariatric surgery to improve their health and begin a new life. Why bariatric surgery? Only 5 percent of people who reach the level of weight that meets the criteria for bariatric surgery achieve a significant amount of sustainable weight loss through diet, exercise or medications. Bariatric surgery can help transform your health and life Studies show that bariatric surgery resolves all obesity-related health problems, such as diabetes and sleep apnea, in about 80 percent of patients. Bariatric surgery can be truly life changing and you will experience several benefits: Enjoy greater overall health. Minimize depression. Decrease menstrual irregularities or pregnancy complications. Slow down premature aging. Improve job performance. Resolve or improve your blood pressure and diabetes problems. Breathe better and sleep better. Resolve acid reflux and urinary incontinence. Reduce painful stress on your weight-bearing joints. Gain confidence. Increase your activity level and begin to enjoy normal activities again. Lower your risks for heart disease and cancer. You can achieve sustainable weight loss and become healthier Many studies have shown that patients who undergo gastric bypass surgery lose 70 percent of their excess weight within 12 months. Similar results can be obtained with a gastric sleeve. OhioHealth Surgical Weight Management provides two surgical options: Roux-en-Y gastric bypass Gastric sleeve 8 OhioHealth Weight Management Surgical Patient Guide OhioHealth.com/WeightManagement 9

The laparoscopic Roux-en-Y gastric bypass procedure It offers consistently reliable results. Many studies have confirmed this operation results in an average loss of 70 percent of excess weight. The top portion of the stomach is stapled closed so food bypasses it. The remaining portion becomes a smaller gastric pouch the size of a small egg. The small size restricts food intake. The gastric bypass procedure resolves diabetes and sleep apnea about 80 percent of the time and resolves high blood pressure and elevated cholesterol about 70 percent of the time. The small intestine is divided into two sections. A 40-inch Roux limb is created from the middle 40 inches of the small intestine. There is low risk of obesity recurrence. The Roux limb is connected to the small gastric pouch, allowing food to bypass other portions of the small intestine and reducing the amount of calories absorbed by the body. OhioHealth Surgical Weight Management selected this surgical option because it effectively achieves sustained weight loss. Patients commonly lose 80 percent of excess weight in the year following the procedure, and sustain 50–70 percent of excess weight loss for decades. The change in anatomy can lead to several vitamin and mineral deficiencies. This problem is corrected by taking calcium and vitamin supplements. An iron supplement also may be needed, especially for menstruating women. Vitamin and calcium supplements should be continued for life. Why select a gastric bypass procedure? There are low risks of long-term complications, as long as patients maintain adequate vitamin and mineral supplementation. Why gastric bypass works There are four reasons why a Roux-en-Y gastric bypass procedure gives superior results. Each of these is important, but together they provide excellent sustainable weight loss. Gastric restriction The size of the functional stomach decreases from a potential volume of approximately two liters to about the size of a small egg. Because of the decrease in size, it is no longer possible to eat the same volume of food previously consumed. Malabsorbtion A portion of the small intestine is either physically or functionally no longer available to absorb nutrients, resulting in weight loss. Reduced hunger A study published in the New England Journal of Medicine suggests there is a hormonal component to this operation. Certain cells found within the wall of the stomach secrete the hunger-stimulating hormone called ghrelin. This hormone peaks before each meal and stimulates the sense of hunger. After the Roux-en-Y gastric bypass operation is completed, this hormone no longer spikes, and presumably no longer causes episodes of hunger. This may explain why many patients do not feel the same level of hunger between meals they previously felt. Biofeedback When patients eat beyond what is recommended, the excess empties into the small intestine where it is quickly diluted with body fluids, instead of being absorbed over time as it would be in a normal-size stomach with a larger reservoir. This response is called dumping syndrome. Symptoms felt by the patient in these instances include a very rapid heartbeat, upper abdominal discomfort, sweating and a general sense of anxiety. These symptoms do not resolve for at least 25 minutes. Because of these potential symptoms, patients are more likely to comply with the recommended diet. Other operations address some of these components, but the Roux-en-Y gastric bypass procedure is the only one to address all four. 10 OhioHealth Weight Management Surgical Patient Guide OhioHealth.com/WeightManagement 11

Laparoscopic gastric sleeve procedure The gastric sleeve procedure reduces the volume of the stomach to about the size of a small banana. Reducing the size of the stomach also reduces hunger, because the part of the stomach that produces the hunger hormone, ghrelin, is removed. Advantages of the gastric sleeve procedure: No cutting, bypassing or stapling of the intestine. Less concern about vitamin and calcium absorption. No adjustments or artificial devices put into place. After one year, the weight loss experienced by patients who have this surgery is normally slightly less than those who have a gastric bypass procedure. Before having bariatric surgery, I was as tired every morning when I got up as when I went to bed. Everything was an effort all da y long. Now I have more energ y, and vitality. I’m happier and healthier! 12 OhioHealth Weight Management Surgical Patient Guide OhioHealth.com/WeightManagement It’s made me reprioritize things in my life, and it’s been such a good investment. 12 13 OhioHealth Weight Management Surgical Patient Guide OhioHealth.com/WeightManagement 13

Risks of laparoscopic gastric bypass or laparoscopic gastric sleeve procedures Laparoscopic surgery – The preferred method Advanced laparoscopic technology allows the Roux-en-Y gastric bypass procedure to be performed more safely. The surgery is far less invasive than traditional surgery, since it is performed through several small “keyhole” incisions. Patients benefit from: Possible Risk Preventive Measure or Solution A leak from the staple line connecting the stomach and small intestine During surgery, the staple lines are secured with the stomach and small bowel is checked at the end of the operation. Excellent cosmetic results. Occasionally, this requires an urgent second operation to repair. A shorter hospital stay. Tiny incisions, resulting is less scarring and quicker recovery. Less pain. Fewer wound complications. Quicker return to physical activity. Much less risk of hernia formation. 14 Deep vein thrombosis: formation of blood clot in the veins of the legs or pelvis pumps and blood thinner injections will be used. In the hospital, you will be encouraged to walk soon after surgery, and special stockings, leg or foot. Anastomotic stricture: a narrowing of the between the new gastric pouch and intestine as a result of the healing process. This narrowing can be dilated through a scope connection as an outpatient procedure, if necessary. Pulmonary embolism: a blood clot that travels from the legs or pelvis to the heart and lungs pumps and blood thinner injections will be used. In the hospital, you will be encouraged to walk soon after surgery, and special stockings, leg or foot. If you are at high risk, your bariatric surgeon may have a removable filter placed in the large vessel that returns blood to the legs, so that large clots cannot reach the heart or lungs. Incisional hernia: a defect in the abdominal wall. This is rare in laparoscopic surgery, but can be repaired with surgery. Bowel obstruction: scar tissue that creates an obstruction or intestinal blockage. Surgery can correct the obstruction. Marginal ulcer This condition can be managed with medication, such as a stomach acid inhibitor, as well as avoidance of nicotine and anti-inflammatories. Mortality This is a safe operation. The risk of mortality from a gastric bypass operation is less than 0.5 percent, up to 30 days following the procedure. OhioHealth Weight Management Surgical Patient Guide Greatly reduced need for a second major operation to repair an incisional hernia. At age 57, my weight was killing me, and I had little hope for recovery. I was taking all kinds of pills for all kinds of disorders. Four months after my surgery, my need for medicine was completely gone! Now, I suspect I’ll be around to rock my great-grandchildren! OhioHealth.com/WeightManagement 15

Pros and cons of two bariatric procedures Eligibility requirements for bariatric surgery Both procedures we offer are safe and effective surgical approaches to sustainable weight loss, but each operation has unique risks and benefits. This side-by-side comparison can help with your decision. Your bariatric surgeon will also provide guidance so you make the best choice for your situation. Body Mass Index (BMI) greater than 40, or BMI greater than 35 with serious comorbidities, such as diabetes, hypertension, obstructive sleep apnea or cardiovascular disease. Age 18 or older. You must be an acceptable medical risk (as defined by the medical evaluation). 16 Laparoscopic Roux-en-Y Gastric Bypass Laparoscopic Gastric Sleeve Rapid weight loss (12 to 18 months) Rapid weight loss (12 to 18 months) Estimated loss of excess weight 70 to 80 percent 60 to 80 percent Resolution of medical problems Excellent diabetes: 84 percent Good High blood pressure: 68 percent Sleep apnea: 80 percent Return to work 3 to 4 weeks 3 to 4 weeks Supplements Vitamin and calcium supplements needed Vitamin and calcium supplements needed Average length of hospital stay Two nights Two nights Mortality rate Less than 1 in 200 Less than 1 in 200 Office visits Six in the first year Six in the first year OhioHealth Weight Management Surgical Patient Guide Previous unsuccessful nonsurgical weight-loss attempts. In-person or online attendance of an OhioHealth Surgical Weight Management seminar. Review of this handbook. OhioHealth.com/WeightManagement 17

Free seminars Presurgical education OhioHealth Surgical Weight Management offers several seminars each month to help you learn about our services. Each seminar is presented by one of our highly-qualified bariatric surgeons. Insurance coordinator In the free seminar, you will: Learn about bariatric surgery options at OhioHealth Riverside Methodist Hospital directly from our experienced surgeons. Learn the information you need to help you decide if bariatric surgery is right for you. Hear stories from past bariatric patients. Learn about the OhioHealth Surgical Weight Management program. Become much more informed about bariatric surgery. If you wish, before you leave your free seminar, you may provide health insurance information to the OhioHealth Surgical Weight Management insurance coordinator, so we can begin to assess your health insurance coverage for bariatric surgery. Our insurance coordinator will call you to explain your health insurance benefits and answer any questions you have. If you choose to proceed with our program, the insurance coordinator will guide you to your next step. Bariatric orientation Your bariatric orientation will provide information to help prepare you for your upcoming journey. Representatives from Nutrition, Exercise and Behavioral Health will provide a brief presentation. You will receive a journal that will guide you through your preoperative education, surgical procedure, postoperative care and after care services. Medical evaluation In order to make sure that bariatric surgery is appropriate and safe for you, a full medical evaluation is completed. The physician will do a complete physical exam, review your health history and discuss your health status with you. You also will have blood drawn for tests, including a complete blood count, chemistry analysis, lipid profile and thyroid studies. A chest X-ray and an electrocardiogram (EKG) are ordered. If the physician feels you need additional diagnostic testing, these tests will be arranged for you at this time. These may include a cardiac work-up with a stress test and an echocardiogram. Occasionally, catheterization may be necessary. Sleep studies are often a part of this process as well, since obstructive sleep apnea is a frequent medical condition caused by severe obesity. Other studies are tailored to your needs and only those studies necessary for your safety are ordered. Psychological evaluation This is an important element of our program that helps prepare you for the lifestyle changes you will need to make to sustain your weight loss after surgery. It also helps our team make a final decision about your readiness for the procedure. During your evaluation, you will complete psychological testing in addition to a one-on-one interview to help the psychologist learn more about you, and your readiness to make lifestyle changes. If the psychologist and the interdisciplinary team concludes that counseling or other recommendations are needed to prepare you for optimal outcomes, you will be referred to another experienced provider who will assist you. Dietitian consultations One of our dietitians will talk with you about your current and prior eating habits. They will review dietary changes you will be required to make before surgery, and explain how to modify your food choices and portions as well as meal frequency after surgery to help you feel well and successfully lose weight. The dietitian will help assess your readiness to make significant dietary changes, and these consultations will help you and the OhioHealth Surgical Weight Management team make a final decision about whether or not you are ready to proceed to surgery. You will be assigned a nurse navigator and care coordinator to answer any questions or concerns you have, and provide guidance throughout your journey. Every single person in the program has been super supportive. 18 OhioHealth Weight Management Surgical Patient Guide OhioHealth.com/WeightManagement 19

Surgery preparation Postsurgical treatment plan Presurgical consultation with your bariatric surgeon Extensive nutritional counseling Once your preoperative evaluation and education is complete, and your health insurance approval has been received, you will have a two-hour consultation with your bariatric surgeon and bariatric nurse. During this visit, your surgical operation will be explained to you in detail, you will receive specific instructions. You can also discuss any remaining questions at this time. After your surgery, you will have at least three consultation appointments with the dietitian. Our registered dietitians will help you change your eating habits and make wise choices through every phase of your program – before, during and after surgery. Follow-up visits Medical follow-up visits will be scheduled for you with your bariatric surgeon at two weeks, four weeks, eight weeks, six months and one year after surgery. Every year following your surgery, you should meet with your physician to check for vitamin and mineral deficiencies. Emotional and social support Although you may not realize it now, the changes you experience may significantly impact your emotions, relationships and self-esteem. At OhioHealth Surgical Weight Management, we offer support groups to help you manage this major life change. Increasing activity for long-term weight management Our exercise program usually begins three to four weeks after your surgery, once your surgeon has approved you to begin this activity. An exercise physiologist will design a program specific to your individual needs, including an exercise plan for you to follow at home between sessions. The process starts very slowly and gently, but you will soon be surprised by what you are able to do! This unique feature of our program will help you achieve your weight-loss goals and increase your activity level following surgery. Our patients are often surprised by how much they enjoy these sessions. One facility we recommend is the McConnell Heart Health Center because of the world-class, comprehensive facilities and highly qualified and experienced staff. For more information about the McConnell Heart Health Center, please visit OhioHealth.com/McConnellCenter. It’s the most amazing thing. I’m a new person. I have a new life. 20 OhioHealth Weight Management Surgical Patient Guide OhioHealth.com/WeightManagement 21

Getting started Your insurance company may require the following things to move forward with your procedure: Weight history This can be obtained from your Primary Care Physician, OB-GYN or any other physician where your weight has been taken periodically. Please make this as complete as possible. Explanation of supervised attempts at weight loss This could include working with a dietitian or programs such as Weight Watchers , Jenny Craig and any medically supervised weight-loss programs. A letter from your family doctor or primary care physician Some insurance companies require a

Short hospital stays - patients typically return home within three days. Superior quality . Bariatric Surgery Versus Conventional Medical Therapy For Type 2 Diabetes. New Engl J Med 2012 Apr 26;366(17):1577-85. 3 Colquitt Jl, Picot J, Loveman E, Clegg Aj. Surgery For Obesity. Cochrane Database Syst Rev 2009 Apr 15; (2):Cd003641.

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